Background Food allergy (FA) affects up to 10% of children globally, with clinical symptoms varying from mild to severe, and in rare instances, it is life-threatening. Approximately one in five children with FA experience a food-induced allergic reaction in school, leaving teachers as the first line of intervention. This study aimed to assess kindergarten teachers’ knowledge, attitudes and beliefs regarding FA.
Methods This cross-sectional study enrolled kindergarten teachers in Kuwait using stratified cluster sampling. The Chicago Food Allergy Research Survey for the General Public was used to assess teachers’ knowledge, attitudes and beliefs regarding FA. The overall FA knowledge score was calculated for each participant. The χ2 test was used to assess the differences in the distribution of categorical variables.
Results Responses were obtained from 882 public kindergarten teachers from 63 kindergartens. Most teachers (81.9%) encountered students with FA in their classrooms. Only 13.5% of the teachers reported receiving training in FA. Overall, participants scored an average of 52.2% on the FA knowledge assessment, with participants receiving prior training in FA scoring on average higher than those with no prior training in FA (55.9% vs 51.6%, p=0.005). A few teachers (10.7%) were aware that lactose intolerance was not equivalent to milk allergy. In terms of attitudes regarding FA, only 14.9% of the participants acknowledged that children with FA are teased/stigmatised due to their condition, and 33.7% recognised that avoidance of allergenic food is difficult. Moreover, only 9.9% of the teachers self-reported their ability to use an epinephrine autoinjector.
Conclusions Improved knowledge and awareness of FA among public kindergarten teachers in Kuwait are needed to ensure the safety of children with FA in schools. Teachers should be trained to prevent, recognise and manage FA-related allergic reactions.
Data availability statement
Data are available on reasonable request.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Food allergy affects a considerable proportion of children worldwide, with an increasing trend.
The knowledge of school personnel, specifically teachers, about food allergy has been reported to be inadequate, which hinders proper management of allergic emergencies in classrooms.
There is a need to assess the knowledge, attitudes and beliefs of kindergarten teachers in Kuwait regarding food allergy.
WHAT THIS STUDY ADDS
Kindergarten teachers in our study sample demonstrated insufficient knowledge about food allergy, with participants answering 52.2% of the knowledge-based items correctly.
Receiving prior training on food allergy was associated with increased food allergy knowledge.
Participating teachers underestimated the impact of food allergy on the quality of life and the social and psychological status of affected children.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The findings of this study highlight the need for policies and protocols to ensure the safety of children with food allergy in schools.
Schoolteachers should be trained in the prevention, recognition and management of food allergy reactions.
Food allergy (FA), defined as ‘an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food’,1 is an increasing global public health concern that affects children and adults.2 3 The prevalence of FA varies worldwide, with prevalence estimates ranging between 1% and 10% among children.4–6 Clinical symptoms of a food-induced allergic reaction can vary from mild to severe and, in rare instances, can be fatal, with manifestations involving multiple body systems, including the skin, respiratory, mucosal, cardiovascular and gastrointestinal systems.3 7 In its most severe form, FA can lead to anaphylaxis, which has been described as a generalised or systemic, rapid onset, hypersensitivity reaction that may cause death.8 In addition to its clinical burden, FA has been shown to impact the social and mental health of affected individuals and, among children with FA, this burden extends to the parents/caregivers.9 10 For instance, the health-related quality of life of children with peanut allergy and their caregivers was worse in comparison with healthy individuals.10 Moreover, higher levels of anxiety have been documented among children with FA as compared with children without FA.11
Children spend a significant amount of time in school daily, with reports showing that 16%–18% of children with FA experience a food-induced allergic reaction in school.12 13 Hence, prevention, recognition and management of FA reactions in schools are crucial to the safety of allergic children. Several studies have shown that there is a deficiency in FA knowledge and negative attitudes toward FA among school teachers and nurses.14–17 Such limitations in FA knowledge and attitudes were attenuated by FA-related training, with studies showing improvements in teachers’ FA knowledge, confidence and attitudes following training.18–23 Given that teachers are considered the first line of management in a school setting and child safety is of utmost importance, ongoing assessments and FA training are needed to better prepare teachers. To this end, there is a paucity of studies on kindergarten (preschool/nursery) teachers’ FA knowledge and attitudes, especially in the Arabian Gulf region, where FA is not a rare event.24 25 A prior study among adolescents in Kuwait estimated the prevalence of FA to be 4.1%.25 Therefore, this cross-sectional study was conducted to evaluate the knowledge, attitudes and beliefs of kindergarten teachers in Kuwait about FA.
Study setting, design and participants
Kuwait is geographically divided into six governorates, and the school districts follow a similar geographical division. In the public education system in Kuwait, kindergarten refers to the optional school years before grade 1, which includes kindergarten levels 1 and 2. Kindergarten is also known as preschool, nursery and daycare. In the academic year 2021–2022, the total number of public kindergarten teachers was estimated to be 7086, with all teachers being female. This cross-sectional study enrolled public kindergarten teachers (n=882) throughout Kuwait. A stratified cluster sampling approach was used to select a representative sample of kindergarten teachers. First, Kuwait was stratified according to the six governorates. Second, public kindergartens (clusters) were randomly selected from each governorate (stratum) using a list of kindergartens within each governorate. Since the total number of teachers differed across the six school districts, proportional allocation was used to determine the number of participants (teachers) needed from each school district by estimating weights relative to the total number of teachers in each school district. In total, 63 schools served as recruitment venues, and all the teachers in each selected school were invited to participate. The recruitment period was 16 October 2022–22 October 2022.
Study questionnaire and variables
The Chicago Food Allergy Research Survey for the General Public (CFARS-GP) was used to assess teachers’ knowledge, attitudes and beliefs about FA.26 Minor modifications were made to the CFARS-GP to make it applicable to our setting (ie, Kuwait) and our target study population (ie, kindergarten teachers). The overall FA knowledge score was calculated for each participant by summing the percentage of knowledge items correctly answered by each respondent. Moreover, the study questionnaire gathered sociodemographic data and teachers’ general awareness of the FA emergency plan in the school and their preparedness to manage FA reactions. A variable representing the number of acquaintances with FA a participant knows (ranging from 0 to ≥3) was developed by counting whether the participant’s parents, siblings, spouse, children and/or someone else they knew had FA.
The questionnaire was then converted into a web-based survey. A direct link (QR code) to the study questionnaire was given to each school’s principal or vice principal who was asked to distribute it among all teachers who completed the study questionnaire. A detailed description of the study questionnaire and its variables is provided in online supplemental appendix 1. A description of the changes made to the CFARS-GP is provided in online supplemental appendix 2, and the study questionnaire is available in online supplemental appendix 3.
Analyses were conducted using SAS V.9.4 (SAS Institute,). The statistical significance level was set at 5% (α=0.05) for all the association analyses. Descriptive analyses were conducted to calculate the frequencies and proportions of categorical variables. The FA knowledge score variable was described by calculating the mean and SD. The χ2 test was used to assess the associations between categorical variables. To control for false positive results due to multiple testing, we applied the false discovery rate (FDR) method to estimate adjusted p values.27
Description of study sample
The characteristics of the study sample are presented in table 1. A total of 1801 teachers across 63 kindergartens were invited to participate in the study, of whom 882 (49.0%) completed the study questionnaire. Respondents represented all six governorates proportionally, according to the teachers’ geographical distribution (table 1). Most enrolled teachers were in the age ranges of 30–34 years (33.7%) and 35–39 years (25.4%). Of the total participants, 16.8% ever had FA, 66.2% had at least one acquaintance with FA and 81.9% had a student with FA in their classroom (table 1). Moreover, only 13.5% had received training in FA.
Knowledge of FA
Table 2 shows the items used to assess FA knowledge. The overall mean FA knowledge score was estimated to be 52.2% (range 8.3%–87.5%), which represents the average proportion of correct answers to the total items assessing FA knowledge. Only 10.7% of the participants were aware that lactose intolerance was not the same as milk allergy. Most participants (81.7%) were aware that hives was a common symptom of FA. Peanuts were identified as the most common (83.2%) childhood FA trigger. Very few participants (18.4%) indicated that there was no cure for FA. However, the majority (73.0%) of the participants correctly acknowledged that avoidance was the only way to prevent an FA reaction.
In an additional analysis (online supplemental table 1), we assessed whether FA knowledge scores differed according to whether the participants had received prior training in FA. Participants who received prior training in FA had higher overall mean FA knowledge scores than those who did not receive FA training (55.9% vs 51.6%, p=0.005, FDR-adjusted p=0.042; online supplemental table 1).
FA attitudes and beliefs
Table 3 shows participants’ perceptions, attitudes and beliefs about FA. Few teachers (14.9%) believed that children with FA are teased/stigmatised at school, 33.7% indicated that avoiding allergenic foods is difficult and 47.7% agreed that having injectable epinephrine (EpiPen or Twinject; also called epinephrine autoinjectors) is important for children with severe FA. Most respondents (62.9%) agreed that schools should have plans to keep children with FA safe. However, only 34.9% of participants agreed that schools should ban all products with nuts.
In further analysis (online supplemental table 2), FA perceptions, attitudes and beliefs were stratified according to whether the participant had any acquaintances with FA. This analysis showed that, overall, participants who knew people with food allergies were more engaged in this health issue and were motivated to witness change. For example, those with at least one acquaintance with FA compared with those with none were more likely to agree that it is difficult for people with FA to safely eat at restaurants (51.5% vs 45.0%, p=0.008, FDR-adjusted p=0.010; online supplemental table 2).
General knowledge of emergency interventions
Online supplemental table 3 presents data on general knowledge of emergency interventions. Of all participants, only 25.2% were aware that their respective schools had an FA emergency action plan. The majority (82.7%) correctly identified the most frequent symptoms of FA (ie, urticaria, stomachache, wheezing), and approximately half (50.1%) correctly identified the most frequent symptoms of anaphylaxis (ie, urticaria, itching, stomachache, wheezing, throat tightness, collapse). Additionally, only 3.1% of the participants knew that intramuscular epinephrine was the best medication for anaphylaxis and severe FA reactions. Lastly, only 9.9% (online supplemental table 3) of the teachers self-reported their ability to use an epinephrine pen (EpiPen).
This study evaluated kindergarten teachers’ knowledge, attitudes and beliefs regarding FA in Kuwait. Our findings demonstrate that FA knowledge varied across the assessed FA knowledge domains, with most teachers correctly identifying peanuts as the leading food allergen in children. However, very few participants were able to indicate that lactose intolerance is different from milk allergy. Moreover, FA knowledge was higher among participants who had received prior training than among those who had not. Regarding participants’ attitudes and beliefs towards FA, very few participants agreed that children with FA were stigmatised. More than half of the participants agreed that schools should have plans to keep children with FA safe. Overall, our study showed that FA knowledge among kindergarten teachers is insufficient in some domains.
Our study estimated an overall mean FA knowledge score of 52.2%. This overall FA knowledge score is lower than the estimated FA knowledge score (64.9%) among the general public in the USA,28 and lower than FA knowledge score estimates among teachers in the United States reported by Canon et al (70.8%)19 and Kanter et al (69.7%).11 Our study and the aforementioned studies have used the same CFARS-GP instrument to assess FA knowledge. Hence, these comparisons show that kindergarten teachers in Kuwait lack sufficient FA knowledge compared with teachers in the USA.
We observed variability among the items assessing knowledge of FA. For instance, only 10.7% of the participants in our study correctly indicated that lactose intolerance was not the same as milk allergy. This result is much less than what was reported by Kanter et al (63%).11 In contrast, participants scored highest in items pertaining to knowledge about symptoms and severity, with the majority identifying hives as a common sign of an allergic reaction to food. In both our study and the study by Gupta et al,28 peanuts, as compared with eggs and milk, were the most commonly reported FA triggers among children. In a study conducted in Italy to measure FA knowledge among schoolteachers and principals, similar findings were found, with the highest score achieved in questions about symptoms of FA, anaphylaxis and the most common FA triggers.15 In addition, there was an evident weakness in knowledge regarding FA treatment, where only 32.8% of respondents correctly indicated that daily medicine intake cannot prevent the occurrence of an FA reaction, and only 18.4% of participants correctly stated that there is no cure for FA. In contrast, 65% of teachers in the USA were aware that daily use of medicine cannot prevent FA reactions and 69% were aware that FA cannot be cured.11 Nonetheless, the majority of respondents (73%) knew that avoiding allergens was the only way to prevent an FA reaction.
We observed higher overall knowledge scores among teachers with prior training in FA than among teachers without previous training (online supplemental table 1). This was also demonstrated in an interventional study conducted among teachers in the USA, which showed that FA knowledge scores increased by 19% in the group that received FA training compared with the control group.19 Another study has shown that teachers who received an educational session improved their understanding of causal foods, signs of anaphylaxis, and proper treatment of local and systemic FA reactions compared with the control group.20 Overall, these findings suggest that proper education and training increase knowledge of FA. Hence, to ensure children’s health and safety in schools, training teachers in FA is essential to reduce accidental exposure and adequately manage FA-related emergencies.
The results of this study showed that teachers underestimated the impact of FA on quality of life and mental health, with only 33.7% indicating that avoiding allergenic foods is difficult, and 14.9% agreeing that children with FA are teased/stigmatised at school. A prior study in Italy reported similar findings, with a minority of school personnel acknowledging the emotional consequences (37.2%) and social difficulties (10.2%) of children with FA.15 Moreover, FA-related bullying is not uncommon, with studies reporting that as many as 40% of children with FA have been bullied for their FA.29–32 Such bullying experiences might have long-term consequences on a child’s development and well-being. Among children with FA (aged 7–14 years), 100% indicated, ‘I want other kids in my class to know not to tease or bully someone with food allergy’.33 Therefore, to protect children with FA from such hardships, it is essential to make schoolteachers aware of the possible psychosocial impact of FA.
Our study is in agreement with previous studies showing deficiencies in establishing and implementing emergency management plans for relieving allergic reactions in schools.16 18 34 Only a quarter of our study participants (25.2%) reported that an emergency plan exists in their school for managing allergic reactions. Additionally, only 3.1% knew that intramuscular epinephrine was the best medication for anaphylaxis and severe FA reactions, and only 9.9% of the teachers self-reported the ability to use an epinephrine pen. These results raise serious concerns about the lack of preparedness of kindergarten teachers and schools in Kuwait to manage in-school FA reactions. Since it has been reported that, in most cases, the first adult to become aware of an allergic reaction in school is the teacher, it would be beneficial to train them to recognise and manage signs of anaphylaxis, especially considering that delays in treating anaphylaxis are associated with poor outcomes.35 36
The results of this study can only be generalised to public kindergarten teachers. Additionally, the response rate (approximately 49%) was low, which may have resulted in nonresponse bias. We would imagine that non-response (self-selection) bias, if any, will lead to an overestimation of the FA knowledge score, as people interested in the topic would be more motivated to participate. Nonetheless, our study covered a large proportion of the target population: 63 out of 200 schools were included in the study, and data were collected from 12.5% (n=882) of the total target population (kindergarten teachers; n=7086). To increase the representativeness of our study, we used proportional allocation sampling. Furthermore, data were collected anonymously to reduce social desirability bias.
In conclusion, the knowledge and awareness of FA among public kindergarten teachers in Kuwait are insufficient. As the prevalence of FA in children of preschool age is high, teachers, as first-line responders to classroom emergencies, must be trained to prevent, recognise and manage FA-related reactions. In addition, injectable epinephrine must be made available on school campuses and teachers must be trained to administer epinephrine in emergencies promptly to ensure the safety of children. Collectively, policies and protocols that ensure the safety of children with FA are needed and should be enforced.
Data availability statement
Data are available on reasonable request.
Patient consent for publication
The study was approved by the Health Sciences Center Ethics Committee for Students Research at Kuwait University (no. 2736/2022). Participants gave informed consent to participate in the study before taking part.
We would like to acknowledge the help and support of all school administrators in facilitating the conduct of this research. We are sincerely grateful to all teachers who participated in this study.
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
LM, SA, HA, FA, DA, FA and SA contributed equally.
Contributors LM, SAll, HA, FAll, DA, FAlk and SAls contributed to the conception, design and planning of the study; contributed to the data analysis and interpretation; and drafted the manuscript. AA contributed to the study design, planning, and data analysis. AHZ contributed to the conception, design and planning of the study; supervised the study implementation; contributed to data analysis and interpretation; and revised the manuscript. All the authors critically revised the manuscript for important intellectual content. The manuscript has been read and approved by all authors. AHZ is responsible for the overall content as the guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.